Volume 16 | Issue 11
Macrene Alexiades MD PhD|No abstract details for the moment.
Geraldine Cheyana Ranasinghe BS and Adam J. Friedman MD|
The seborrheic keratosis is the most common benign skin tumor of middle-aged and elderly adults, affecting nearly 83 million individuals in the US alone. Although these are benign lesions, many patients still undergo some form of treatment. Clinicians are frequently presented with a challenge when determining whether to remove a seborrheic keratosis, and which treatment modality to use when doing so. The most commonly used method of removal is cryotherapy, however there are numerous other options that can be employed with varying degrees of efficacy. In this article, we highlight the use of topical keratolytics, vitamin D analogues, and lasers, to name a few. We also address potential side effects associated with these treatment options, as well as discuss patients’ preferences and concerns. We conclude with the most recent advances in topical treatments currently under clinical investigation, and offer treatment strategies aimed at maximizing patient satisfaction.
J Drugs Dermatol. 2017;16(11):1064-1068.
Treatment of Photoaging With a Dual-Wavelength, 532 nm and 1,064 nm Picosecond-Domain Laser Producing a Fractionated Treatment Beam Using a Holographic Optic
Eric F. Bernstein MD MSE,a Kevin T. Schomacker PhD,b Amit S. Paranjape PhD,b Jayant D. Bhawalkar PhDb|
BACKGROUND: A dual-wavelength, picosecond-domain, fractionated laser delivering 1,064nm and 532nm laser energy through a holographic optic was investigated for safety and effectiveness at improving the appearance of chronic photoaging. MATERIALS AND METHODS: A total of 27 subjects were enrolled with 24 completing the study, and 14 subjects were treated with 1,064 nm and 10 with 532 nm. The 1,064 nm-treated subjects received 5 monthly treatments while the 532 nm-treated subjects received 4 monthly treatments. Improvement was measured by blinded evaluation of pre- and post-treatment images 12 weeks following the final treatment. Subjects also evaluated treatment effect and side-effects. RESULTS: Blinded reviewers correctly identified the baseline image in 52 of 72 paired images, or 72% of the time, with a mean improvement score of 1.4 using an 11-point rating scale (P less than 0.0001). Post-treatment erythema, mild edema, and petechiae were the only side effects noted. CONCLUSION: The fractionated, picosecond-domain, 532 nm and 1,064 nm laser is safe and effective for improvement of facial photodamage. The laser was well tolerated with mild erythema, edema, and petechiae as the most common side-effects.
J Drugs Dermatol. 2017;16(11):1077-1082.
In-Vivo Histological Analysis of a Fractional CO2 Laser System Intended for Treatment of Soft Tissue
Elisabeth Hurliman MD,a Brian Zelickson MD,b Jeffrey Kenkel MDc|
BACKGROUND: Fractional ablative lasers have been shown to be safe and effective for improving wrinkles, scars, skin texture, and dyspigmentation. However, the exact effects of this technology in vivo on epidermal and dermal skin constituents have not been delineated. This study evaluated the in vivo histological effects over time of treatment with a fractional ablative CO2 system, using different treatment parameters. MATERIALS AND METHODS: Healthy adult volunteers were enrolled in this multicenter clinical study. Study participants, previously scheduled for abdominoplasty, received fractional CO2 laser treatment on the abdomen at a predetermined time prior to surgery. Biopsies were taken at baseline and after CO2 treatment. Morphological and morphometric analyses were performed in the ablated and coagulated tissue areas. RESULTS: Nine healthy adult volunteers were treated. Histologic evaluation showed 800-900 micron diameter zones of ablation and coagulation confined to the upper most layer of the skin in the mode with the greatest fractional skin coverage using Light Mode 30 - 50% (spot diameter of 150 microns, 30-60 millijoules fluence), while ablation to levels of up to 900 microns in depth using the Deep Mode (spot diameter 150 microns, 50-80 millijoules). Healing times of treated tissue varied from 1-day post-treatment with the Light Mode, and up to 10 days post-treatment with the Deep Mode. No remnants of ablation or coagulation were seen after 30 days post CO2 treatment with either mode. There were no adverse events associated with treatments. CONCLUSION: Treatment of the skin using the fractional CO2 device leads to skin resurfacing via ablation and coagulation of the treated area at a depth proportional to the delivered energy. The higher the energy used, the greater the degree of ablation and coagulation in tissue, which can lead to a greater tissue response in terms of fibroblast activity, collagen remodeling, and new collagen formation.
J Drugs Dermatol. 2017;16(11):1085-1090.
Lana X. Tong MD MPH and Jeremy A. Brauer MD|Introduction: Acne vulgaris is common dermatologic condition with an estimated prevalence of 70 to 87%. Acne has been shown to have a significant impact on patient quality of life and mental health, especially as inflammatory lesions typically occur on cosmetically sensitive areas with the potential for permanent scarring. There have been numerous advances in the treatment of inflammatory acne with light-based and laser devices. Objective: To review the current evidence for light-based and laser treatments in the management of inflammatory acne. Methods: An analysis was conducted of PubMed indexed English language literature regarding management of inflammatory acne using light-based and laser treatments. Results: Evidence for the utilization of laser and light-based therapy for acne was summarized in a comprehensive review. Laser and light-based treatment holds the advantages of improved patient compliance and safety profiles in comparison to pharmacologic therapy. Efficacy of device based treatment varied in comparison to standard topical treatment regimens, often more effective when used in combination therapy. Adverse effects reported were generally self-limited. Discussion: These treatments do and will continue to play an important and enlarging role in the management of acne. Larger scale studies with standardization of treatment protocols are warranted.
J Drugs Dermatol. 2017;16(11):1095-1102.
Disparity in Cutaneous Pigmentary Response to LED vs Halogen Incandescent Visible Light: Results from a Single Center, Investigational Clinical Trial Determining a Minimal Pigmentary Visible Light Dose
Teo Soleymani MD,a David E. Cohen MD MPH,b Lorcan M. Folan PhD,c Uchenna R. Okereke MD,b Nada Elbuluk MD MSc,b and Nicholas A. Soter MDb|
Background: While most of the attention regarding skin pigmentation has focused on the effects of ultraviolet radiation, the cutaneous effects of visible light (400 to 700nm) are rarely reported. Objective: The purpose of this study was to investigate the cutaneous pigmentary response to pure visible light irradiation, examine the difference in response to different sources of visible light irradiation, and determine a minimal pigmentary dose of visible light irradiation in melanocompetent subjects with Fitzpatrick skin type III - VI. Methods: The study was designed as a single arm, non-blinded, split-side dual intervention study in which subjects underwent visible light irradiation using LED and halogen incandescent light sources delivered at a fluence of 0.14 Watts/cm2 with incremental dose progression from 20 J/cm2 to 320 J/cm2. Pigmentation was assessed by clinical examination, cross-polarized digital photography, and analytic colorimetry. Results: Immediate, dose-responsive pigment darkening was seen with LED light exposure in 80% of subjects, beginning at 60 Joules. No pigmentary changes were seen with halogen incandescent light exposure at any dose in any subject. Conclusion: This study is the first to report a distinct difference in cutaneous pigmentary response to different sources of visible light, and the first to demonstrate cutaneous pigment darkening from visible LED light exposure. Our findings raise the concern that our increasing daily artificial light surroundings may have clandestine effects on skin biology.
J Drugs Dermatol. 2017;16(11):1105-1110.
A Retrospective Study on Efficacy of Pulsed Dye Laser and Intense Pulsed Light for the Treatment of Facial Telangiectasia
Lin Gao MD PhD,* Ni Gao MD,* Wenting Song MD, Erle Dang MD PhD, Rong Yin MD PhD, Li Wang MD, and Gang Wang MD PhD|
Both pulsed dye laser (PDL) and intense pulsed light (IPL) systems have been demonstrated to be effective for treatment of facial telangiectasia, however there have been very few comparative studies between both treatments involving purely Asian patient populations. In this study, we performed a retrospective analysis to compare the efficacy of PDL and IPL systems for the treatment of facial telangiectasia. A total of 416 patients with facial telangiectasia who were treated by PDL or IPLs in our department from August 2012 to March 2015 were included in this study. The subjects received one of the following five treatments: PDL 595 nm (9-12 J/cm2), MaxG (500-670 nm & 870-1200 nm, 30-46 J/cm2), IPL (560-1200 nm, 18-24 J/cm2), M22 560 (560-1200 nm, 15-18 J/cm2), and M22 590 (590-1200 nm, 15-20 J/cm2). Each treatment had two sessions with 6-week intervals. The improvement percentage score in facial telangiectasia after the final treatment was evaluated by two non-treating physicians. We found almost all patients (less than 95.00%) had marked improvements or nearly complete clearance of the lesions after PDL 595 nm or MaxG treatment, as compared to 41.38%-56.58% patients in the other three groups that showed similar degrees of improvements. Both PDL 595 nm (9-12 J/cm2) and MaxG (500-670 nm & 870-1200 nm, 30-46 J/cm2) treatments resulted in significantly superior vessel clearance than the IPL systems with other wavelength bands (560-1200 nm or 590-1200 nm) and relatively lower fluence (15-24 J/cm2). Our results also suggested fluence levels account for the significant differences in the effectiveness delivered by different IPL systems. We concluded that PDL 595 nm and MaxG showed comparable clinical efficacy and both treatments resulted in most beneficial outcomes.
J Drugs Dermatol. 2017;16(11):1112-1116.
Efficacy of Low-Fluence Nd:YAG 1064 nm Laser for the Treatment of Post-Inflammatory Hyperpigmentation in the Axillary Area
Sahar Ghannam MD PhD,a,b Fatemah K. Al Otabi,c Konstantin Frank,d and Sebastian Cotofana MD PhDe|
OBJECTIVE: Post-inflammatory hyperpigmentation results in aesthetically unpleasant discoloration of the skin in the affected area. The efficacy of low-fluence Q-switched 1064-nm Nd:YAG laser has so far not been evaluated for the treatment of the axilla. This observational study was designed to evaluate whether the application of the laser treatment can satisfactorily reduce axillary hyperpigmentation. MATERIAL AND METHODS: 17 females (mean age, 34.27 ± 9.24; range, 19–48) were treated in a single center between 2014 and 2016 for post-inflammatory hyperpigmentation of the axillary area. One treatment session was done every 2 weeks. Pairwise pre- / post-treatment assessment was graded by the practitioner, the patient, and an independent non-medical observer for consistency using a standardized grading scale. RESULTS: Post-treatment evaluation revealed an improvement score of 4 ± 0.44; range, 4–5 (good improvement) with a variance of 0.19 after the treatment. The scoring of the practitioner rs= 0.31 correlated higher with the patient-related outcome than with the scoring of the independent non-medical observer rs= 0.17. The minimum number of sessions needed for an excellent patient-evaluated improvement was 3, but an increased number of sessions was not significantly correlated with the outcome. The results of the treatment lasted for at least 6 months after the last session. CONCLUSION: A low-fluence Q-switched 1064-nm Nd:YAG laser provided safe and effective treatment for post-inflammatory hyperpigmentation in the axillary area, with good-to-excellent improvement after a minimum of 3 sessions.
J Drugs Dermatol. 2017;16(11):1118-1123.
A Randomized, Investigator-Blinded Comparison of Two Topical Regimens in Fitzpatrick Skin Types III-VI With Moderate to Severe Facial Hyperpigmentation
Monique J. Vanaman Wilson MD,a Isabela T. Jones MD,b Joanna Bolton MD,c Lisa Larsen DO,d Douglas C. Wu MD PhD,e and Mitchel P. Goldman MDe,f|
Purpose: Though hydroquinone (HQ) remains the gold standard for treatment of hyperpigmentation, concerns about its safety have prompted the development of HQ-free topical skin lightening systems. Objective: To compare the efficacy and tolerability of a new HQ-free system and a popular HQ-based system for the improvement of facial hyperpigmentation and photoaging in darker skin types. Methods: This investigator-blinded trial randomized 30 subjects of Fitzpatrick skin types III to VI with moderate to severe hyperpigmentation to a new 7-product HQ-free system or a 7-product HQ-based system for 12 weeks. At 4, 8, and 12 week follow-up visits, a blinded investigator assessed efficacy and tolerability using standardized scales. Subjects also performed a self-assessment at each visit. Summary: Both the HQ-free and HQ-based systems produced significant improvements in Overall Hyperpigmentation that were sustained through week 12 (P=0.008, 0.0003). The HQ-based system demonstrated better improvement in overall hyperpigmentation at weeks 4, 8, 12 (P=0.01, 0.001, 0.003, respectively). Mottled Pigmentation Area Severity Index (MoPASI) scores improved with both systems (P=0.02, 0.01), with no statistically significant differences between the two treatment groups. Subject-rated hyperpigmentation was not different between groups. Subjects reported significantly more discomfort with the HQ-free system at week 8 (P=0.02); otherwise, measures of irritation were the same between groups. All irritation was described as mild to moderate. At week 12, 100% of subjects in the HQ-free group and 92.3% of subjects in the HQ-based group were satisfied with their outcome. Conclusion: Both a new HQ-free skincare system and a widely-available HQ-based system improved hyperpigmentation in Fitzpatrick skin types III to VI. Though the HQ-based system produced greater improvement in hyperpigmentation when compared to the HQ-free system, there was no difference in MoPASI scores between the treatment groups. Subjects were satisfied with both treatments and reported only mild to moderate irritation using either system.
J Drugs Dermatol. 2017;16(11):1127-1132.
Linda Stein Gold MD,a Hilary E Baldwin MD,b Tina Lin PharmDc|
Acne vulgaris (acne) is the most common skin disease we see in dermatology practice. Although rare in childhood, severe acne can affect up to 12% of the adolescent population. A chronic disease, it requires both aggressive management and effective maintenance strategies. Oral antibiotics, in combination with topical agents are recommended for treatment, with topical agents being continued as maintenance therapy to minimize resistance and recurrence. However, concerns with systemic side effects have recently resulted in a greater focus on the potential of fixed combination topical therapies to treat severe acne. Here we review the available clinical evidence. There are no studies investigating the use of fixed combination topical therapy exclusively in severe acne. However, studies assessing the treatment of moderate-to-severe acne include subpopulation data in severe patients. Adapalene 0.3%-benzoyl peroxide (BP) 2.5% was found to be effective in patients with severe acne, whereas the fixed combination with a lower concentration of adapalene (0.1%) was no more effective than vehicle. Clindamycin-BP 1.2%/3.75% gel and clindamycin-BP 1.2%/2.5% gel were both found to be effective in severe acne with an apparent BP-dose response. Clindamycin phosphate 1.2%-tretinoin 0.025% demonstrated similar efficacy in severe acne, but with little benefit over individual monads. Realistic topical treatment options now exist for the management of severe acne where patient and physician preference can impact positive outcomes.
J Drugs Dermatol. 2017;16(11):1134-1138.
Lauren C. Strazzulla BA, Lorena Avila MD, Kristen Lo Sicco MD, Jerry Shapiro MD|
Lichen planopilaris (LPP) is a variant of lichen planus that affects the scalp causing scarring hair loss. Patients also frequently experience symptoms of scalp itch, pain, and burning. To date, there are no long-term remittive nor curative therapies available. Low-dose naltrexone has anti-inflammatory properties and has recently been described in the context of treating autoimmune conditions. This retrospective medical record review describes four LPP patients treated with low-dose (3 milligrams per day) naltrexone. This medication provided benefit in these four patients including reduction in symptoms of pruritus, clinical evidence of inflammation of the scalp, and disease progression. All patients tolerated naltrexone without adverse effects. This is the first case series demonstrating the beneficial effects of low-dose naltrexone for patients with LPP. This medication was well-tolerated by the patients and is cost-effective.
J Drugs Dermatol. 2017;16(11):1140-1142.
Katelyn Mariko Updyke BS,a Amor Khachemoune MD FAAD FACMSbc|
Port-wine stain (PWS) is the second most common congenital vascular malformation characterized as ectatic capillaries and venules in the dermis that clinically appears as a deep red to purple patch on the skin. Typically, PWS progressively darken and may become hypertrophic or nodular without treatment. There are several treatment options available for PWS from topical antiangiogenic agents to laser therapies. Vascular-specific lasers are the gold standard in treating PWS and classically pulsed dye lasers are usually the treatment of choice. However, some patients with PWS are recalcitrant to PDL and may require a combination of treatment methods. Nonetheless, even with the advancements in laser therapies utilized today, it is can be difficult to achieve complete clearance of the PWS. Thus, new innovations for treating recalcitrant PWS are underway in order to improve overall patient treatment outcomes.
J Drugs Dermatol. 2017;16(11):1145-1151.
Christine M. Pennesi BS,a John Neely MD,b Ames G. Marks Jr. MD,b and S. Alison Basak MD MAb,c|
Atopic dermatitis and prurigo nodularis result from complex interactions between the skin, the immune system, and the external environment. The pruritus associated with these conditions greatly impacts patients’ quality of life and lacks uniformly effective treatment. A 57-year-old patient presented with severe atopic dermatitis and subsequent prurigo nodularis refractory to numerous standard therapies. The supplement isoquercetin was initiated and he noted significant, sustained reduction in his pruritus after only four weeks. Isoquercetin is a glycoside derivative with antihistamine properties of quercetin, a natural polyphenol flavonoid found in many plants. It may offer itch relief in patients who have failed more conventional therapies.
J Drugs Dermatol. 2017;16(11):1156-1158.
Sowmya Nanjappa MD, Matthew Snyder PharmD, and John N. Greene MD FACP|
Extravasation of medications can manifest as tenderness, pain, tissue necrosis, and thrombophlebitis and lead to infection and severe long-term complications. Risk factors for leakage of medications include mechanical and pharmacologic mechanisms such as cannulation technique, vasoconstriction, and cytotoxicity. Well-known vesicants like anthracyclines, vinca alkaloids, and vasopressors are usually administered with proper caution. Often overlooked are many antimicrobial agents, which typically act via differences in osmolality and pH. Vancomycin harms the vascular wall by the latter (pH 2.5-4.5). Although similar in appearance to vancomycin hypersensitivity reactions (eg, linear immunoglobulin A bullous dermatosis), we present a patient whose dermatitis and subsequent cellulitis likely originated due to extravasation of the drug from the peripheral intravenous catheter. The visible dermatitis mimicked bullous cellulitis from toxin-producing Staphylococcus aureus, Group A Streptococcus, and gram-negative rods or anaerobes in the setting of neutropenia. Our case illustrates the importance of getting an appropriate history and recognizing non-infectious causes of rashes that mimic chronic infections.
Anthony Chiaravalloti MD,a Ali Banki DOb,c,d|
Amelanotic melanoma (AM) is one of the great masqueraders in dermatology. It is a very difficult clinical diagnosis to make because these tumors are devoid of pigment and other clues of melanoma. They are commonly misdiagnosed clinically as other benign and malignant conditions. We present a new case of AM in an 84-year-old woman with a history of non-melanoma skin cancer. She had a thin pink plaque that was initially misdiagnosed as a basal cell carcinoma. We also discuss dermoscopy and its valuable role to improve diagnostic accuracy. A review of dermoscopic features that favor and oppose the clinical diagnosis of AM is discussed. Even with dermoscopy, it is still important to have a high index of suspicion and a low threshold to biopsy when the clinical diagnosis is unclear.
J Drugs Dermatol. 2017;16(11):1164-1165.
2017 ODAC CONFERENCE ARTE POSTER WINNER: Bioinformatics Analysis of the Inflammatory Acne Transcriptome Supports Mechanisms of Action for Current Treatments and Predicts Novel Therapies In Vivo
Rivka C. Stone MD PhD and Marjana Tomic-Canic PhD|Acne vulgaris, a common disorder of pilosebaceous follicles, adversely affects quality of life in patients. Formation of papules and pustules in inflammatory acne is orchestrated by a sustained host immune response whose features are incompletely understood, impeding the development of novel targeted therapies. To this end, we utilized transcriptome data previously obtained from lesional and non-lesional skin of 18 patients with inflammatory acne. We identified an acne “signature” of 217 genes that were coordinately up-or down-regulated in lesional skin of patients from two cohorts. Pathway analysis was enriched for biological processes of innate and adaptive immunity. We employed bioinformatics techniques to identify drugs predicted to target acne-relevant immune processes through their known effects on the expression of subsets of inflammatory acne “signature” genes. Using this approach, we linked minocycline to modulation of neutrophil and lymphocyte migration via its downregulation of IL1B, IL6, CXCL8, and CCR2 expression that is increased in lesional acne skin in vivo. Similar networks were constructed for tretinoin and salicylic acid therapies. Finally, we predicted a novel role for small molecule inhibitors of MEK/ERK signaling in the treatment of inflammatory acne. Taken together, our findings suggest that bioinformatics approaches can be successfully employed in the discovery an development of acne therapeutics.
J Drugs Dermatol. 2017;16(11):1166-1169.
NEWS, VIEWS, & REVIEWS: Memory Age: What It Is, Why It’s Important, and Practical Applications for Medical Aesthetics Practitioners
Lovely Laban MSN GNP-C|
A recent study by a leading medical aesthetics practice has revealed that women have a “Memory Age” that is about 10 years younger than their actual age. Skin by Lovely (Portland, OR; Santa Monica, CA) asked 350 women ages 30-70 to reveal their Memory Age. Participants were asked to close their eyes, conjure up a mental picture of themselves, and state what age they looked in their minds.
Julia Schwartz, MD, Thomas Lee, MD|
The content of these case studies, ideal to review during peer study groups, was developed by Julia Schwartz, MD and Thomas Lee, MD under the guidance of dermatologist Adam Friedman, MD, FAAD, Associate Professor of Dermatology, Residency Program Director, Director of Translational Research, Department of Dermatology GW University.
New Insight Into the Multifactorial Pathophysiology of Hair Loss: Inflammation, Stress, and Follicle Biology Take Front Stage
Kircik, et al.|
As our understanding of the microenvironment of the hair follicle deepens, it is becoming increasingly clear that targeting a single pathway in this complex system is not ideal. Androgens, cortisol, and corticotropin-releasing hormone, all of which are not in balance in hair loss due to internal and external stress, and gene expression of pro-inflammatory mediators all affect the hair follicle to suppress “normal” function and negatively influence hair growth.
Leon H. Kircik MD|
While there are a number of products that can help healthy hair look healthier, shampoos or vitamins alone can’t truly regrow thinning hair. As dermatology providers, we realize this not only because we know the science, but because we see patients in the clinic every day who ask us how they can help to reverse hair loss and improve the quality of their hair.
New Insight Into the Pathophysiology of Hair Loss Trigger a Paradigm Shift in the Treatment Approach
Neil S. Sadick MD,a Valerie D. Callender MD,b Leon H. Kircik MD,c,d,e,f,g Sophia Kogan MDh|
Hair loss affects millions of men and women of all ages and ethnicities, impacting appearance, social interactions, and psycho-emotional well-being. Although a number of options are available, they are limited, carry a potential risk of side effects, and none have proven to be comprehensive for treatment of hair loss. Across the spectrum of hair loss disorders, there has long been a segmentation into distinct mechanisms, driving the main trend in current therapeutics to focus on targeting single molecules or pathways. However, research points to similar dysregulation of intrinsic signaling pathways within follicle physiology that span the hair loss disorder spectrum – with a common inflammatory component identified in most hair loss pathogenesis, including that of androgenetic alopecia (AGA).
J Drugs Dermatol. 2017;16(11 Suppl):s135-140.
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Patricia K. Farris MD,a Nicole Rogers MD,a Amy McMichael MD,b Sophia Kogan MDc|
Hair loss is a complicated problem that causes significant concern for those who are affected. Patients seeking medical treatment have limited options that include topical minoxidil and oral finasteride. While these treatments are backed by long term clinical use and research outcomes, many patients find topical minoxidil difficult to incorporate into their daily routine and some are concerned with the side effects associated with finasteride. In the office setting, patients may be treated with more invasive procedures such as platelet-rich plasma injections (PRP) and hair transplantation, treatments that often must be repeated and can lead to a costly investment. Consumers are increasingly interested in natural treatments for hair loss. Many turn to basic supplements only to be disappointed when they fail to deliver due to lack of standardization and efficacy. In this paper we review the benefits of a nutraceutical containing a specific blend of highly purified, standardized, bio-optimized, and bioavailable botanical extracts to treat hair loss. These phytoactives were selected because of their diverse multi-modal biologic activity against inflammation, DHT, stress mediators, oxidative damage, and intermediary signaling cascades. This supplement represents a paradigm shift as it addresses not only the factors that trigger hair loss but the downstream mediators of inflammation as well. Multi-center clinical studies are currently underway to confirm the efficacy and benefits of this unique nutraceutical.
J Drugs Dermatol. 2017;16(11 Suppl):s141-148.
THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE.
PLEASE SCROLL DOWN TO ACCESS THE FULL TEXT OF THIS ARTICLE WITHOUT LOGGING IN.
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